The exact circumstances leading up to the occurrence could not be determined. The horizontal sliding watertight door was not being operated in accordance with the manufacturer's specifications for minimum closing time.Findings as to Causes and Contributing Factors The exact circumstances leading up to the occurrence could not be determined. The horizontal sliding watertight door was not being operated in accordance with the manufacturer's specifications for minimum closing time. The practice of not fully opening the watertight door before attempting to pass through it increases the risk of a personal accident. The relatively quick closing time for the watertight door subjects the transient to undue risk. The location of the operating levers for the three local watertight door stations was less than optimal, and the operation of the levers to open and close the doors was not consistent among all three doors. There is no Canadian regulation that addresses the minimum and maximum closing times for sliding watertight doors, and the guidance provided in SOLAS and by the manufacturer was not used to determine the safe operational parameters of the watertight doors.Findings as to Risks The practice of not fully opening the watertight door before attempting to pass through it increases the risk of a personal accident. The relatively quick closing time for the watertight door subjects the transient to undue risk. The location of the operating levers for the three local watertight door stations was less than optimal, and the operation of the levers to open and close the doors was not consistent among all three doors. There is no Canadian regulation that addresses the minimum and maximum closing times for sliding watertight doors, and the guidance provided in SOLAS and by the manufacturer was not used to determine the safe operational parameters of the watertight doors. Weather and sea conditions were favourable and there was no weather-related motion of the vessel.Other Finding Weather and sea conditions were favourable and there was no weather-related motion of the vessel. Safety Action Action Taken Transportation Safety Board of Canada In August 2005, the Transportation Safety Board (TSB) issued a Marine Safety Information (MSI) letter (No. 02/05) addressed to Transport Canada (TC) with a copy to Northumberland Ferries Ltd. The letter informed both parties of the TSB's observations regarding the deficiencies associated with the installation and operation of the watertight door system onboard the Confederation. The observations included: the relatively quick closing time for the watertight door; the less than optimal location of the operating lever on all three local watertight doors; the fact that the operation of the levers to open/close watertight doors was not consistent among all three doors; the fact that Canadian regulations do not address the minimum and maximum closing times for sliding watertight doors, and the practice of not fully opening the watertight door before attempting to pass through it. Northumberland Ferries Limited Following the occurrence, the time required for the horizontal watertight door to close from fully opened was adjusted to 26 to 30 seconds per the manufacturer's specifications. The control levers for the horizontal sliding door have been modified to reduce the distance that the operator must reach. The operator can now, on both sides of the door, comfortably hold the levers in the open position while passing through the opening. Also, the door now slides in the same direction that the lever handle is moved. Photo 7. Modifications to watertight door operating lever Photo 8. Modifications to watertight door operating lever A policy has been adopted to be included in the Shipboard Operations Manual, whereby all crew members who have occasion to use any watertight door must be instructed on the safe operation of those doors. This policy includes written instruction on the correct method of using watertight doors. A procedure has been adopted for the inspection and servicing of watertight doors to ensure that they are maintained and operated as recommended by the manufacturer. Items included in this inspection are alarms, signage, and closing and opening times. Transport Canada TC issued Ship Safety Bulletin No. 07/1991 entitled Accidents When Using Power Operated Watertight Doors. The bulletin was issued as a result of a similar incident that occurred on a Canadian ferry prior to May 1991 and is a reminder that all power-operated watertight doors are designed to ensure maximum safety of the ship and to persons using them. As part of Phase 2 of Regulatory Reform, TC will be reviewing and subsequently re-drafting the Hull Construction Regulations to incorporate and/or reference many of the Safety of Life at Sea (SOLAS) regulations, thereby making them applicable to Canadian-registered domestic vessels. The SOLAS requirements for power-operated sliding watertight doors will be referenced in the proposed new Hull Construction Regulations along with the minimum and maximum operating time parameters. TC will also consider augmenting the requirements so that issues such as obstructions in the way of the operating handles that may restrict the proper operation of the controls are also addressed. In a response to MSI letter No. 02/05, dated 1 September 2005, TC's Atlantic Region stated that it had issued a Direction under the Canada Labour Code, Section 8.3.1, on 5July2005 to the captain of the Confederation. Following this, all three watertight doors were adjusted to close in the prescribed time. In the case of the horizontal watertight door, the levers were relocated to make the operation of the door easier; that is, the lever actuates the door in the same direction of travel and the handles are now very close to the door opening.